26 November 2006

Dr Grumble does not want his male and female patients milling around together on the same ward if they are not happy with that. But the average NHS ward does not always make it easy to fully separate the sexes and Dr Grumble would sooner see the sexes together than not have a bed for his patient. And with ever decreasing bed numbers this is the choice our managers have to make.

Dr Grumble does not like having to ask patients about private matters behind some flimsy curtains which just play lip service to privacy. Read the books about how to convey bad news to a patient that is hard of hearing and it is unlikely that it would advise you to shout this information to the patient in an open ward. But these are the realities of today's NHS. Who gets the blame? Sometimes the doctors. But it's not our fault. It's the environment in which we are forced to work.

If our managers were genuinely concerned about patient dignity wouldn't they provide patients with something better than the typical hospital gown? What function do these things serve? What's the betting the hospital managers claim there is some special clinical need? If Dr Grumble wants to examine a sick man in one of these ghastly garments he has to first sit him up, then undo tightly knotted ties then somehow lift the sick patient's bum off the bed and so on. In short, it's a real struggle to expose the patient's chest. What might the patient wear otherwise? Pyjamas perhaps? What could be easier? Unbutton the front and everything is accessible. Sit the patient forward and lift the pyjama top up and the back of the chest is there for auscultation. As for the abdomen, that too is easily accessible if the patient is in pyjamas. Oh and they cover the patient's bum for when they want to walk about. Come on managers, help us a bit! Buy in some pyjamas!

Posted by
Dr Grumble

15 comments:

Great post Dr Grumble - let me share a story with you. As a hospital manager I became a patient many years ago for a very minor surgical procedure, and I was asked to report at 12 noon the day before my surgery, to the surgical ward which, of course, as an obedient patient, I did. The first thing I was asked to do was to get undressed and sit on the bed in my gown. This was 12 noon on a Wednesday - not something I would normally do at 12 noon on a Wednesday. When I asked why, I was told this was the procedure as the consultant would ‘examine me shortly.’ The doctor did not arrive for another couple of hours and when he did it was nothing more than a cursory glance and a chat. No need for me to either be in bed or to be undressed.

My point is … this is procedure and institutionalisation gone mad. We perpetuate old and out of date systems simply for the sake of the institution and nothing to do with patient dignity. It is unfair to blame managers for this. Doctors and Nurses maintain procedures that are designed for the convenience of the staff rather than the dignity of the patient. Another example during my career was my nursing officer friend who became a patient in his own hospital and refused to get into his bed for the consultant’s ward round. He insisted on sitting in his bedside chair because he could see no reason why he should get into the bed. As the nurses blood pressure rose with the impending consultant ward round he insisted that he was going to remain seated in the comfortable set rather than get into bed which was ‘what the consultant wanted’ according to the nurses. He told me that when the doctor arrived he was fine about the patient being in the chair. These myths are created because of the continuance of out of date old systems that no one ever challenges.

I agree with you completely about the lack of dignity for patient with the silly gowns that are provided – my point is there are many outdated and unchallenged procedures and practices that show no respect whatsoever for the patient and they are not all invented by managers. Nurses and yes even Doctors perpetuate procedures that take away patient dignity just as much as managers.

Trevor is quite right it's not all the managers fault. Dr Grumble was being a bit naughty in trying to provoke his one and only reader. But this gown thing is surely something that would be simple to put right.

Dr Grumble once worked for an imperious surgeon who insisted that his breast surgery patients had gowns that fastened at the front (without any gaps) with Velcro fasteners that enabled the relevant part to be speedily examined. It's not rocket science. But these days it's difficult to do this from the shop floor. The power is not with Dr Grumble.

I've always thought that the complete lack of privacy was to remind us to be vigilant.

See no evil - no matter how gaping the gown, always avert your eyes even if it endangers your own safety when walking somewhere. That way, you also get to overlook frightening procedures that are happening over the way from you or nasty messes.

Hear no evil - no matter that the next bed is 18 inches away. And no matter if the family is discussing how one of them swiped another patient's gate bracelet and managed to persuade another family member to sell it to a pawnshop.

Speak no evil - doctors and nurses should always remember that bed curtains are not acoustic mufflers. The corollary of this is that hospital wards are extraordinarily noisy places where few patients manage to get any decent kip and can be very grumbly if woken at 6 for a breakfast that doesn't arrive before 8:30.

To Dr Grumble the 3 simplicity principles sound very plausible and, once you have been told them, very obvious. Perhaps Dr Grumble should buy the book but he wonders if these principles have been implemented anywhere and whether there is evidence that they work.Plainly, if Dr Grumble had his hands on the cash it would be a simple matter to substitute pajamas for gowns so it does seem obvious that it should work. There are many other things Dr Grumble would like to do if he had control of the money. Fewer but much better support staff would be one. It's 10-15 pm and Dr Grumble is still in the hospital and has just finished correcting letters (typed in India) that should have been typed properly the first time. This is a big time waster. Better staff either in India or the UK would avoid this.

Trevor thanks Dr Grumble for kind comments about simplicity principles and yes they are ‘obvious’ – just as wearing seat belt in a car is now – Trevor remembers the days when this was not an ‘obvious’ thing to do.

As regards ‘evidence base’ … Mmmmmm… good question … ‘no’ is the short answer but Trevor says this is ‘hearts and minds’ stuff and a leap of faith is needed when we just ‘feel’ something is right.

On the subject of ‘evidence based’ Trevor seems to remember reading somewhere that effective clinical interventions by doctors are scientifically based in only 20% of cases – i.e. 80% of decisions by doctors are based on ‘how it feels’ based on experience of the doctor … but hey … I am not clinically trained so I am sure Dr Grumble will correct me if I am wrong. Seems to Trevor, medicine is as much an art as a science!

In my management career the three simplicity principles are things I strived for and sometimes achieved. It really is a case of having courage to do the right thing and ‘letting go’ of the ‘power’ you are vested with as manager. Trevor will happily send Dr Grumble a book at half price …. let me know if you are interested but no pressure. You have enough to do if you are still working at 10.15 pm in the office. I am typing this at 25 minutes past midnight so there you go – you are not alone – we are both mad! … just joking.

A half price book! It's as Dr Grumble thought: the hospital managers are trying to find out where he lives. Just joking.

Surprisingly, Dr Grumble has read several management books - mostly by Charles Handy. They opened his eyes to things that have turned out to be so obviously the case that no controlled trial is required - but he was interested in whether or not there was any evidence for the Simplicity Tips. It seems there is none but those Tips seem to have the ring of truth about them.

Aha!!! …..Dr Grumble appears to have worked out Trevor’s evil plan ... even though I am no longer one of those ‘Panto Baddies’ – AN NHS MANAGER!!! ... …..Oh no I'm not!!!

I cannot give you ‘evidence’ the simplicity principles work other than personal experience, subjective anecdotes and stories .... but hey … that sounds a bit like life anyway.

No pressure on the book!! ...since that book last year which was my first I have written three more... the latest is called ‘I Wanna Tell you a Story' which is my reflective piece about lessons I have learned in leadership and management through incidents in my NHS management career of 35 years.

Charles Handy is one of my great heroes and I had the immense pleasure of seeing him 'live' in Birmingham last year - a gifted speaker who talks only common sense and simplicity. I have read all his books.

Take care and watch those working hours ....remember you have a 'life' too.

Hearing Charles Handy speak was what led Dr Grumble to reading his books. But that was nearly 20 years ago. It was partly his influence that resulted in Dr Grumble following a very unusual portfolio career with some 6 years out of clinical work. Through listening to him Dr Grumble was way ahead of the game in understanding the way the world was going.

Most interestingly, when Dr Grumble first decided to return to clinical work he was in an extremely weak position and, unsurprisingly, failed to get a teaching hospital consultant post. Some time later he had cause to phone the professor at the hospital in question who asked why Dr Grumble had not asked for feedback as to why he had not got the job. The reason was that Dr Grumble thought he knew – he was not clinically current enough. Because of this he had decided to turn this weakness into a strength and to emphasise the additional and rather different experience he had had – partly as a manager. The professor told Dr Grumble that the clinicians had all been very impressed with him but that managers were not.

Now isn’t that interesting! Dr Grumble thinks that they did not want a consultant that might threaten them in some way. As it happened Dr Grumble had no intention of getting involved in any management. It was just a way of selling himself. Dr Grumble does essentially no management at present – not in the NHS anyway

One of Professor Handy’s gifts is his ability to make the complex simple – he is truly inspirational. He just tells stories really. I am not surprised you were ahead of the game 20 years ago – I suspect you still are!

Trevor believes Dr Grumble's suspicion about jealous managers is spot on. In my career the most enjoyable and most effective times I enjoyed were when I worked closely with senior doctors. I found the docs I worked with were often better managers than Trevor despite the fact Trevor has all the right management qualifications (and then some)

Many ‘Prima-Donna’ managers do not want to admit this sort of thing. They will hold on to the myth that management is predominantly a science when we all know it is largely an art.

Nowadays as an independent person (free to tell the truth about NHS management) Trevor is coach for a Consultant Vascular Surgeon and we are equals – he is just as good as me at this stuff we call ‘management’

To be frank, Consultants ‘manage’ in their job all the time – as does everyone else in the NHS which leads Trevor to remind Dr Grumble of another simplicity principle – ‘If managers have a job at all in 2006 it is to make the job of front line staff easier.’

This thing about referring to yourselves in the 3rd person is doing my head in.

Trevor, your simplicity tips are oversimplified. I speak as an ex senior manager from the City (ex because I am now retired with cancer). I agree in part with them all, but the repetition of the word ALL is silly.

Dr Grumble, the reason I opened the comments box originally was to say that I always assumed that gowns were designed to make it easy to take them on and off whilst the patient was bedbound (or anesthetised). Surely the first thing the theatre team do after you're out is to whip your gown off? I don't think pj's would work so well.

Another approach would just be to encourage patients to wear their own nightwear unless they were unable to get out of bed or en route to/from theatre. In fact now I think about it, that's what's always happened to me.

potentilla - thanks for your honesty - appreciated. I disagree with you of course but thanks anyway :-)

The only reason we have such complexity in management has to be for the benefit of managers – there really is no other logical explanation for the crap I saw in my long NHS career. Simplicity IS possible in all systems - it is we humans that make it complicated.

I too was a senior manager for many years (35 in fact) in the NHS and there is no doubt whatsoever that the NHS is full of complex language and processes designed BY managers FOR managers and nothing to do with the needs of either front line staff or patients (our customers). This of course is no different than any other management setting.

The sooner we give front line staff the power to determine the direction of the organisation the better as far as I am concerned.

Thanks once again for your comments and my best wishes in your current challenge which makes all this very insignificant anyway – best wishes.

Potentilla, you are presumably right about the reasons gowns are as they are. But people are not necessarily in hospital just for a procedure. Dr Grumble's point is that many patients who are not going anywhere for anything and need encouragement to mobilise are dressed in these things. The old seem to put up with such indignity but young patients will not want to put themselves on display in this way and will lie in bed rather than shown themselves off to the world. It really is time we stopped it. Many patients arriving acutely ill have not brought their night attire with them so this is not always a solution. And keeping track of patients' clothes (which may get nastily soiled) in a very busy hospital is a nightmare.

As for the third person, Dr Grumble is new to blogging. He just started like that and he feels more comfortable distancing himself in this way. He is sorry if it disturbs Potentilla.

I am very sorry to learn of your illness. I hope your experience of hospitals has not been too bad. Most of us are trying our very best.

Thank you both for your good wishes. (I didn't mention the cancer to get the sympathy vote, btw, but just to make it clear that I am an ex-manager for reasons unrelated to the job itself). Yes, thank you, my experience of hospitals has been pretty good, both as a private patient in an English tertiary centre and as an NHS patient in a Highland DGH.

It wasn't so much you using the 3rd person Dr G - am used to that, having been a lurker for a while - but the fact Trevor started using it in reply.

Trevor, this is probably not the place to have a long debate about How to Do Management, but I have a strong view that management is not, in fact, simple, and the desire of many managers and consultants to reduce it to simple (and, particularly, hard-and-fast )rules is the cause of much bad management. the NHS is full of complex language and processes designed BY managers FOR managers; I absolutely agree with that (so is the City); but I think the complex language etc arises BECAUSE of attempts to turn management into something rules-based - "if you just follow our methodolgy it'll all work fine". Your own methodology has the advantage of having fewer words than six-sigma and other garbage, but it is still in the "rules" frame of mind.

Take the pyjamas problem. Do you think that all "staff at the front line" have the same view? What do you think the surgeons would say if their patients turn up in pj's? How do you balance the views of surgeons and Dr Grumble? If you try to make them both happy by having 2 sorts of hospital-provided clothing, what will the nurses say who have to make sure the patient is dressed in the right sort at the right time? What is the role of the patient's own clothing and (allowing for Dr Grumble's points) could it in any way be extended to help solve this problem? Is it in fact worth the extra money to have two sort of hospital clothing available? Are the answers to these questions different in different wards (they will certainly be different in different hospitals)? If so, is there any sense in having different procedures on different wards or wil that just confuse everybody?

The proper job of a manager is to understand which questions needed to be answered, to obtain accurate answers, and (if necessary) to referee a compromise, even (if necessary) to enforce a compromise.

Lots of managers do this badly or not at all. However, that doesn't stop the fact that someone ought to be doing it, and it is generally not sensible to have what you call "front-line staff" doing it, both because they tend to give insufficient weight to the views of other people on the front line, and because they have more specialist things to spend their time on.

I also agree with you that much of what management consultants do is a waste of time and money (I looked at your site some time ago when you commented on Dr Crippen in your own name). But, just sometimes, consultants can also fill the role I outline.

Thanks Potentilla for your excellent response. I can see what you are saying and of course the NHS is a complex organisation but I believe this is largely down to the language we have ‘invented’ as managers.

All professions do it – lets be honest. Car mechanics, plumbers, solicitors, doctors – you name it they all have their own language. That is fine when they discuss things among themselves but I depart from that culture when we involve customers in discussion - in our case patients and/or their carers.

I do believe staff at the front line have the best solutions. They have often been doing the job of direct customer contact for many years and it is arrogant at best on the part of managers to assume they somehow know better.

I think we could delegate much more than we do to front line people in the NHS. Ok, I may come back a bit about saying front line staff know all the answers all the time but I genuinely believe front line staff know about how things get done far better than managers who are often theoretical in approach and have never worked at the front line and may not have seen a patient for a decade or two.